[Carriers of hepatitis C: should they all be vaccinated for hepatitis A?]. / Portadores de hepatitis C: tenemos que vacunarlos a todos frente a la hepatitis A?

AIM: To investigate the prevalence of immunization against hepatitis A virus (HAV) in persons with hepatitis C virus (HCV) infection, in order to determine who should be vaccinated for the former. DESIGN: Descriptive, cross-sectional study. SETTING: Urban health center serving 12 000 inhabitants. PARTICIPANTS: Patients older than 14 years positive for HCV infection. VARIABLES: presence of chronic liver disease, serological indications of hepatitis B, A, and immune deficiency virus (HIV) infection, vaccination for hepatitis B. RESULTS: A total of 134 persons (70.9% men and 29.1% women) comprised the sample of patients positive for HCV infection. Mean age was 41.75 years (SD, 16.55 years). Nearly all patients (93.3%) had chronic liver disease, 56.7% were intravenous drug users, 56% were positive for Hbc antibodies and 32.8% were positive for HIV. Serological testing for HAV was done in 75 patients (56%); the result was positive in 86.7%. Mean age in this subgroup was 50.4 years (SD, 17.8 years). In the HAV-negative subgroup, mean age was 36.6 years (SD, 15 years; P=.02). Serological testing for HAV could not be done in 44% of the patients: 33.6% did not respond to attempts to contact them by telephone or in writing, 6% were temporarily away from home, and 1 patient declined to be tested. The response to requests to obtain blood samples was better in women (66.7%), HIV-negative patients (34.7%), persons who were not intravenous drug users (43.3%) and persons with chronic liver disease (60%). CONCLUSIONS: In persons younger than 40 years, the proportion of seronegative individuals is similar to that in the general population. Vaccination should be considered for all patients positive for HCV infection. In persons older than 40 years with chronic liver disease, the decision to vaccinate for HAV should be made in the light of serological findings.

Portadores de hepatitis C: ¿tenemos que vacunarlos a todos frente a la hepatitis A? / Carriers of hepatitis C: should they all be vaccinated for hepatitis A?

Objetivo. Estudiar la prevalencia de inmunización frente al virus de la hepatitis A (VHA) en personas infectadas por el virus de la hepatitis C (VHC), con el fin de indicar la vacunación. Diseño. Estudio descriptivo transversal. Emplazamiento. Centro urbano (12.000 habitantes).Participantes. Pacientes positivos para el VHC mayores de 14 años. Mediciones principales. Variables: presencia de hepatopatía crónica, serologías de hepatitis B y A e inmunodeficiencia humana (VIH), vacunación de hepatitis B. Resultados. La muestra de pacientes positivos para el VHC se componía de 134 personas, el 70,9 per cent varones y el 29,1 per cent mujeres. Edad media: 41,75 (DE, 16,55) años. El 93,3 per cent presentaba hepatopatía crónica, el 56,7 per cent era usuario de drogas por vía parenteral (UDVP), el 56 per cent era HBcAc positivo y el 32,8 per cent VIH positivo. La serología del VHA se realizó a 75 pacientes (56 per cent), y fue positiva en el 86,7 per cent. La edad media en los pacientes VHA+ era de 50,4 (DE, 17,8) años, y en VHA- de 36,6 (DE, 15) años (p = 0,02).Al 44 per cent de los pacientes no se pudo determinar la serología VHA: un 33,6 per cent no respondió a los mensajes telefónicos ni a las cartas enviadas, un 6 per cent estaba ausente temporalmente y un caso no aceptó hacerse la analítica. La respuesta a la realización de la prueba fue mejor en las mujeres (66,7 per cent), en pacientes VIH-(34,7 per cent), en no UDVP (43,3 per cent) y en hepatópatas crónicos (60 per cent).Conclusiones. En menores de 40 años, la proporción de seronegativos es similar a la de la población general y se debería considerar la vacunación en todos los pacientes VHC +. En mayores de 40 años y en los pacientes con hepatopatía crónica se debería investigar el estado serológico para vacunar contra la hepatitis A (AU)

Hepatitis C, infección por el virus de la inmunodeficiencia humana y retraso en el diagnóstico. Respuesta / Hepatitis C, HIV infection and delay in diagnosis. Reply

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[Temporal disability caused by psychiatric pathology at a health center]. / Incapacidad temporal por patología psiquiátrica en un centro de salud.

OBJECTIVE: To find the incidence, duration, diagnosis and treatment of time off work for psychiatric reasons. DESIGN: Retrospective, descriptive study. SETTING: The Dr. Pujol i Capsada Health Centre in Baix Llobregat county, Barcelona. PARTICIPANTS: All the records of time off occurring between January 1992 and December 1996 were reviewed. Time off for psychiatric reasons, and its length, follow-up, relapses and treatment were analysed. MEASUREMENTS AND MAIN RESULTS: 71 patients had had time off on some occasion for psychiatric reasons (34% men, 66% women). The mean age was 38 (SD 10). The mean number of days off in the first period of time off (n = 71) was 155 days (SD = 302), in the second (n = 21) 209 (SD = 268), in the third (n = 8) 187 (SD = 327), and in the fourth (n = 3) 206 days (SD = 326). Total number of days off came to 16,894. 4% obtained invalidity status for psychiatric reasons. The most common initial reasons for the first period of time off were, by pathology: psychiatric (58%), osteo-muscular (17%), nervous system and sense organs (7%) and digestive system (6%). The psychiatric reasons for the first period off were: anxiety (48%), depression (38%), anxiety-depression (10%), schizoid disorders (3%) and personality disorders (1%). Half the patients were referred and almost all were supervised by the general practitioner. The most commonly used drugs were the benzodiazepines (75%) and serotonin re-uptake inhibitors (38%). CONCLUSIONS: Time off for psychiatric reasons tends to last a long time and to recur. 42% of these periods of time off was not initially classified as for psychiatric reasons. Half the patients are shared and supervised jointly with the psychiatrist: thus, the need for good coordination between the two areas.

Incapacidad temporal por patología psiquiátrica en un centro de salud / Health centre report on short-term time off work due to psychiatric pathology

Objetivo. Conocer la incidencia, duración, diagnóstico y tratamiento de las bajas laborales por causas psiquiátricas. Diseño. Estudio descriptivo retrospectivo. Emplazamiento. Un centro de salud (ABS Dr. Pujol i Capsada), situado en la comarca del Baix Llobregat (Barcelona). Participantes. Se revisaron todos los registros de las bajas producidas entre enero de 1992 y diciembre de 1996 analizando las causadas por motivo psiquiátrico, duración, seguimiento, recaídas y tratamiento. Mediciones y resultados principales. Han estado de baja alguna vez por motivo psiquiátrico 71 pacientes (34 por ciento varones, 66 por ciento mujeres). La media de edad era 38 años (DE, 21). La media de días de incapacidad en la primera baja (n = 71) era de 155 días (DE, 302), en la segunda (n = 21) de 209 (DE, 268), en la tercera (n = 8) de 187 (DE, 327) y en la cuarta (n = 3) de 206 (DE, 326). El total de días de baja fue de 16.894. Obtuvo la invalidez por motivo psiquiátrico un 4 por ciento. Los motivos iniciales más frecuentes de la primera baja fueron por patología: psiquiátrica (58 por ciento), osteomuscular (17 por ciento), sistema nervioso y órganos de los sentidos (7 por ciento) y digestiva (6 por ciento). El motivo psiquiátrico de la primera baja fue ansiedad (48 por ciento), depresión (38 por ciento), ansiedad-depresión (10 por ciento), trastornos esquizoides (3 por ciento) y de personalidad (1 por ciento). Se derivaron la mitad de los pacientes y casi todos fueron controlados por el médico de cabecera. Los fármacos más empleados fueron benzodiacepinas (75 por ciento) e inhibidores selectivos de la recaptación de serotonina (38 por ciento). Conclusiones. Las bajas por motivo psiquiátrico suelen ser largas y recurrentes. Un 42 por ciento de bajas no estaba clasificado inicialmente como motivos psiquiátricos. La mitad de los pacientes son compartidos y controlados conjuntamente con el psiquiatra, de aquí la necesidad de una buena coordinación entre los dos niveles (AU)

Do knowledge and attitudes about influenza and its immunization affect the likelihood of obtaining immunization?

A telephone survey was conducted on 190 patients in Barcelona, Spain, at high-risk for influenza to evaluate the relationship between their knowledge and attitudes toward influenza and influenza immunization and whether they received the immunization. A discriminant function correlates (r = 0.86) with the immunization behavior and predicts the behavior before flu immunization in 84% of cases if we know the previous immunization behavior and adequately classifies the behavior in 82% if we don't know it (r = 0.75). Modifiable factors that predict immunization are self-identification as high-risk, belief that the immunization will not cause discomfort, intention to be immunized, and physician assigned. Those not immunized had a prevalent feeling that the shot is not effective, that they are not susceptible to the illness, and that the health center does not offer satisfactory organization to provide immunization. Furthermore, they felt that they had received controversial information through the mass media. We therefore believe that health education activities regarding influenza immunization should be specifically directed to increasing awareness of those who belong to a high-risk group, as well as to emphasizing susceptibility to the illness and the innocuousness of the immunization.

Prevalence and determinants of alcohol consumption among schoolchildren in Barcelona, Spain.

The pattern of use of alcoholic beverages and factors influencing it among Barcelona schoolchildren were studied; 2,255 fifth and eighth grade students from 71 schools completed a self-administered questionnaire. Between fifth-eighth grades, important changes take place in attitudes--strongly opposed to alcohol among the younger, much more moderate among the older. Family celebrations such as Christmas or birthdays are the earliest source of exposure to alcohol, at which one-third of fifth grade students and two-thirds of eighth grade students drink. In eighth grade, though daily consumption is relatively rare (4.4% for boys), a considerable proportion have been drunk at least once (16% of girls and 19% of boys) or have had four or more drinks in a row, while a small but significant proportion (2.5%) have been drunk two or more times in the last six months. A discriminant analysis uncovered some features predicting this "higher risk" use of alcohol: age and gender (being a boy in eighth grade), lower socioeconomic status, higher weekly allowance available for personal expenses, a pattern of usual consumption by both the father and friends, smoking regularly, and having a moderate or high physical activity level, as well as holding opinions in favor of drinking.

[Cancer of the urothelium: background and characteristics of the care process related to the prognosis in a series of clinical cases]. / Cáncer urotelial: antecedentes y características del proceso asistencial relacionadas con el pronóstico en una serie clínica.

We analyze the occupational and smoking histories of 98 bladder cancer patients in a Barcelona City general hospital (Spain). Only 12 patients had no history of occupational risk or of smoking; 38 had an occupational history associated to higher bladder cancer incidence, and 80 had been or were current smokers. Diagnostic delay and delay in the initiation of treatment are analyzed. Up to 24% of patients delayed visiting their general practitioner over three months after the onset of hematuria. Up to 21% took more than three months in seeing an urologist. Only 38% began treatment in hospital in the first three months after diagnosis. The greater proportion of infiltrative tumours is seen in patients below 65 years who were visited with delay for their hematuria.

[Compliance of antibiotic treatment in primary health care. Value of the personalized prescription]. / Cumplimiento del tratamiento antibiótico en atención primaria de salud. Valor de la receta personalizada.

A controlled clinical study was carried out in order to evaluate the efficacy of a personalized prescription as a measure to improve the fulfillment of a short course antibiotic treatment. 180 patients completed the study (96 in the active group and 88 in the control group) finding no differences in selected variables between the two groups. Evaluation of treatment fulfillment was performed with an interview and counting the pills, finding with this method that 57.94% of the patients fulfilled the treatment. Except for a higher incidence of adverse side effects in the control group (p less than 0.05) no other significant differences were found between the two groups. The interview showed a 37% sensibility and a 97% specificity, which was specially usefull in the detection of nonfulfillers. The correlation coefficient between both groups was 0.66 (p less than 0.001). Our results suggest that the personalized prescription does not improve the patient compliance achieved by a good verbal information in the short course antibiotic treatment.

Renal handling of bilirubin photoderivatives.

The renal handling of unconjugated bilirubin in the dark and during light exposure was analyzed using an isolated rat kidney preparation. The parameters tested were pigment disappearance from the perfusion medium, pigment uptake by tissue, and its renal clearance. The results indicated that despite the fact that pigment disappearance from the medium was similar for both forms of pigment, the extraction ratio was higher for irradiated pigment than for pigment in the dark. When renal clearance of pigment was plotted vs pigment uptake of tissue, the results indicated that irradiated pigment may be more efficiently removed by the kidney. In addition, data on the rate of secretion of p-aminohippurate suggested that both pigment forms shared a common site for secretion.

Possible mechanism of unconjugated bilirubin toxicity on renal tissue.

1. The effects of unconjugated bilirubin on rat renal tissue metabolism and organic anion transport were investigated using cortical slices. 2. Unconjugated bilirubin in the medium decreased slice-to-medium ratio of p-aminohippurate, altered intracellular Na+ and K+, and decreased ATP content without modifications of (Na+-K+) ATPase. 3. The effects were similar to those of ethacrynic acid and cyanide but less marked. 4. The presence of probenecid blocked the effect of pigment on intracellular electrolytes. 5. The results suggest that pigment is taken up by renal tissue using the organic anion transport system, and within the cell inhibits ATP production.

Evidence for a secretory component in the handling of unconjugated bilirubin by the isolated perfused rat kidney.

Previous studies in rats have suggested that the urinary excretion of unconjugated bilirubin (UB) comprises only a small fraction of the pigment that reaches the tubular lumen by glomerular filtration and escapes from tubular cell reabsorption. However, additional data also indicated that UB interacts with renal peritubular cell membranes impairing the secretion of p-aminohippurate (PAH). In this study we examined the possibility of a secretory step which could also be involved in the renal excretory mechanism for UB. An isolated rat kidney preparation was used, and the uptake of UB by renal tissue, the UB appearance in the urine, and the secretion of PAH were analyzed throughout the perfusion. The results indicated that the UB urinary excretion rate changed independently of UB filtered load. The latter remained almost unchanged during the perfusion, whereas the excretion rate of UB and the UB-to-creatinine (Cr) clearance ratio increased significantly. Furthermore, a relationship between the uptake of UB by the kidney, the UB-to-Cr clearance ratio, and the decrease in PAH secretion rate, was proved. In addition, when probenecid was added to the perfusate solution the cumulative uptake of UB by the kidney and the rate of excretion of UB in the urine were diminished. We conclude that the mechanism of UB excretion by the kidney may be considered as the result of a process involving glomerular filtration plus tubular secretion followed by a back diffusion step from the lumen in a similar way to other endogenous compounds, thus explaining the virtual absence of UB from the normal urine.

Distal nephron function of the rat during acute aflatoxicosis.

The effect of an acute intoxication with aflatoxin B1 (AFB1) on some parameters of distal nephron function was examined in rats 48 h after a single i.p. dose of 100 micrograms/kg body wt. The parameters tested were the capacity for the excretion of fixed acids and ammonium salts during metabolic acidosis and the concentration and dilution of urine applying conventional clearance techniques. The treated rats showed a glomerular filtration rate (GFR) approx. 50% lower than the controls, but they were able to reduce the urinary pH as were nonintoxicated animals. The ammonium excretion rate per ml of GFR was unimpaired in the treated rats, but the rate of excretion of fixed acids per ml of GFR was increased. The maximal urinary osmolality was significantly diminished in the intoxicated rats as was water reabsorption, when compared with data obtained in the controls. No differences between groups were seen in the free water formation although urinary excretion of electrolytes was significantly increased. The studies support the nephrotoxicity of AFB1 in the rat probably by interfering with transport function in the collecting tubule cells together with a diffuse impairment of proximal tubule function, as observed previously.

Alterations in renal function induced by aflatoxin B1 in the rat.

The effects of aflatoxin B1 (AFB1) on renal function were determined in adult male Wistar rats by in vivo and in vitro studies. In vivo studies demonstrated that AFB1 decreased glomerular filtration rate, tubular reabsorption of glucose, and tubular transport for p-amino-hippurate. Furthermore, AFB1 pretreatment increased urinary excretion of sodium and potassium and urinary gamma-glutamyl transferase content. In vitro studies showed that slices of renal cortical tissue obtained from AFB1-treated rats (100 microgram/kg) exhibited a diminished capacity to accumulate p-aminohippurate. On the other hand, total water content of tissue, amount of extracellular water, and intracellular sodium were increased. Intracellular potassium was diminished by treatment with AFB1. Although the molecular species responsible for the effects is not known, these results indicated that AFB1 is nephrotoxic in the rat following a single low dose (100 microgram/kg body wt, ip).

Inhibitory effect of unconjugated bilirubin on p-aminohippurate transport in rat kidney cortex slices.

The effects of unconjugated bilirubin on the accumulation of p-aminohippurate, kinetics of p-aminohippurate uptake, the efflux of pre-accumulated p-aminohippurate and water and electrolyte distribution were investigated in the rat kidney cortical slice. (2) The addition of unconjugated bilirubin to the incubation medium decreased the 60 min slice-to-medium concentration ratio of p-aminohippurate. (3) The decrease in p-aminohippurate accumulation by unconjugated bilirubin was found to be more pronounced by increasing the concentration of pigment in the medium. (4) The rate of uptake of p-aminohippurate as a function of p-aminohippurate concentration differed in aerobiosis and anaerobiosis, and unconjugated bilirubin decreased only the uptake of p-aminohippurate in aerobic conditions. (5) The efflux of pre-accumulated p-aminohippurate decreased when unconjugated bilirubin concentration in the medium was low (10-20 microM) but the efflux increased when the concentration of pigment was much higher (100 microM). (6) The addition of unconjugated bilirubin to the medium (40-100 microM) increased intracellular sodium and total tissue water content, and decreased intracellular potassium and oxygen consumption of tissue. However the slices incubated with low concentration of pigment (20 microM) did not exhibit significative changes in cellular functional parameters. (7) These findings suggest that unconjugated bilirubin impairs p-aminohippurate transport by a complex mechanism that might involve binding of pigment to sites necessary for anion transport, although effects related to pigment toxicity or to its oxidative decomposition are not excluded.

Peritubular interaction of unconjugated bilirubin in isolated perfused rat kidney.

1. The interaction of unconjugated bilirubin with peritubular cell membranes of the rat kidney was studied by means of an isolated rat-kidney preparation applying the multiple-indicator-dilution technique. 2. Inulin was used as an extracellular marker and p-aminohippuric acid as a model of organic anion that interacts with the peritubular membrane. 3. A single renal artery injection of a mixture containing inulin and unconjugated bilirubin was followed by the appearance of the two compounds in the venous effluent. The unconjugated bilirubin curve was always under the curve of inulin and its mean transit time was always less than that of inulin. 4. The cumulative venous recovery of inulin was higher than that of unconjugated bilirubin. 5. When unconjugated bilirubin uptake was plotted against the injected dose of pigment the relationship suggested a saturation phenomenon. 6. The recovery of p-aminohippuric acid was significantly increased when unconjugated bilirubin was added. 7. The results provide evidence for the interaction of unconjugated bilirubin with the peritubular cell membranes of rat kidney.

Effect of unconjugated bilirubin on the uptake of p-aminohippuric acid by the isolated perfused rat kidney.

The effect produced by unconjugated bilirubin (UB) on p-aminohippuric acid (PAH) translocation from plasma to the urine, was analyzed by using an isolated rat kidney preparation applying the multiple indicator dilution technique. Arterial -to- urine mean transit times and fractional recoveries of creatinine and PAH in the venous effluent, were calculated before and after the incorporation of UB into the system. PAH influx into cells, its efflux from the cells to the capillaries, and its movement between lumen and tubular cells were also calculated. The results indicated that PAH influx into cells was impaired in the presence of UB. The phenomenom was shown to be dose-dependent. On the contrary, the efflux of PAH to the capillaries that was also impaired by UB, seemed to be unrelated to the pigment concentration within the system. Movement of PAH between lumen and tubular cells also appeared to be affected by UB. The results obtained suggested that UB interferes with the renal handling of PAH but the mechanism involved could not be clarified with the model used.